Hazards to Public Health

By Cawasji

Reactions from members of the medical profession to my column last week on the sorry state of the medical education scenario in Pakistan and the worries of the British General Medical Council about Pakistani doctors employed in the UK were, with one exception, totally in agreement with the assessment presented.

The ‘exception,’ however, did agree that a proper reply must be sent to the GMC. But who can write what?

According to one doctor e-mailer, Pakistan produces far too many mediocre doctors. His calculation is that of the 10,000 doctors sent out from our medical colleges each year, some 100 are excellent, some 500 are good, and around 1,000 average. The rest are, he suggests, a hazard to public health.

His reading of why the United Kingdom has a problem with Pakistani doctors is that it gets what he terms the ‘leftovers’, as most young doctors try to get to the US. Those who are unable to go there, accept jobs in the UK and Ireland doing ‘scut’ work in some mediocre hospitals where training is unstructured and delivered in dribs and drabs.

This may be so, but it is certainly no justification for the state of our medical institutions and for the ineptitude and corruption of many who run them. To take the premier institution, the Pakistan Medical and Dental Council, the controlling body from whence all powers medical flow. It is run from behind the scenes by a Council member, who manipulates his fellow members and the man he props up as president.

Syed Muhammad Awais, Professor of Orthopaedic Surgery, King Edward Medical College, and Associate Dean, Postgraduate Medical Education, University of Punjab, sent me the following message on the subject of the Council which I have his permission to reproduce :

“First of all I thank you for your very clear article published in Dawn of 8th Jan 2006, on recent developments of the PMDC, I hope this will help in sorting out this problem.

“I have been a member of the PMDC since 2000, and was also executive member from 2001-2005. Despite all my efforts to bring quality assurance in the functioning of the Council, I could only contribute to the writing of a new Code of Ethics for medical and dental practitioners and guidelines for authors, editors and reviewers of research papers, in 2002. In the day-to-day decisions, I would like to see improvements in PMDC affairs.

“The internal politics which you have briefly touched in your article is largely responsible for not allowing the PMDC to become transparent and standardized and to function as a 21st century ‘professional regulatory body.’

“The PMDC Ordinance of 1962, and Act of 1973, required the PMDC to develop ‘regulations for its different operations’ and to further develop transparent ‘Operating Procedures’ (based on the world’s most modern knowledge) and to improve them from time to time so that the institution could perform well. Only this could have allowed inspection / review of the PMDC itself. Unfortunately, despite the repeated efforts of a few members this could not take place.

“As you have very rightly mentioned in your article, the freedom to express enjoyed by us today, is much more than in the past, and this facility must be used in a right way to promote/support the truth for protecting the rights of the public rather [than] looking after the interests of a few selected ones.

“We should with courage admit that mainly responsible for the inefficiencies of PMDC in the past and present crises are its own members (including me). PMDC exercised its autonomy without accepting its full responsibilities in many areas, including, inter alia : (1) protecting the public from bad medical and dental practitioners. (2) Maintaining the registers of database regarding medical and dental practitioners and inspecting whether practitioners are practising without registration or when retired or dead. (3) Launching minimum health care standards for different health care delivery organizations. (4) Revising the schedules of medical and dental qualifications which were written before partition. (5) Developing the modern systems of accreditation of undergraduate and post-graduate medical education, and implementation of its calendar of periodic evaluations. (5) Creation of legal cover for its examination and fee charged for re-examining foreign qualifications.

“The lack of modern standards of transparency, quality assurance, democratic decision-making and accountability are common problems of most of the public organizations in our country, and the PMDC is certainly no exception.

“The people and government of Pakistan, in the best interest of the state and society, must (1) launch modern concept of public policy, thereby allowing participation of the public and stakeholders in decision-making; (2) respect and enjoy the freedom we have while accepting the responsibilities of efficiency, quality and accountability; (3) devolve the powers to lower but collective levels (committee work) so that the king-pins cannot ever ‘hijack’ an organization; (4) discourage the selection of leaders by the state establishment and encourage public and stakeholders to choose their own leaders; (5) strengthen the rule of the law instead of the rule of the ruler. These measures could enable the PMDC and all other public organizations to function well.

“I have heard that there is a new ‘Law of the PMDC’ in the making which will be presented in the Assembly. This bill (law) has not been subjected to public / professional debate (not even discussed among the existing PMDC members). Such bills are always polar, and do not serve the public correctly. Where the PMDC and other public bodies must function correctly, the law-making should also follow the right path. We must willingly accept our rightful roles. (Ameen)”

Dr Asim Hussain, Chancellor of Ziauddin Medical University, frankly and openly admits that medical education in this country “has gone to the dogs.” Junior doctors, the leaders in an emergency situation, are grossly ill-trained both in knowledge and in expertise. And, according to Dr Hussain, the blame for the decline in this country’s health system rests squarely on the PMDC and on the CPSP and its president.

He reminded me that on January 6, a four-member bench of the Supreme Court, headed by our proactive Chief Justice Iftikhar Muhammad Chaudhry, directed the PMDC to cease its discriminatory practices vis-a-vis applications for the recognition of degrees and to formulate an authentic principle. The PMDC’s dual and discriminatory standards are illegal and unconstitutional and create mistrust among the public.

It is not only the medical authorities of the United Kingdom and Ireland who have worries and concern about Pakistani graduate doctors obtaining employment in their countries. Feedback has it that Malaysia has found that post-graduate students have been shown up to be inadequately trained, and in Australia medical authorities treat Pakistanis with the utmost suspicion, given their known proclivity for mischief when it comes to their CVs and such matters. One Pakistani doctor, who is trying to get on with his life in Ireland, has decided to identify himself as an Indian for employment purposes.

We, and the president and prime minister, need to get our act together all round, in all fields of education, administration, business practices — you name it. But we could make a start somewhere and where better than in a profession whose members are under oath to save the lives and limbs of others — and not to maim or kill them.